论文部分内容阅读
目的分析漏编“另编码”的因素,加强手术操作编码的完整和准确。方法通过计算机检索2012年-2013年1万份手术病案,详细了解主要手术操作的情况,根据手术分类编码原则校对编码。结果 1万份病案中,手术操作遗漏“另编码”的有2100份,占检查份数的21%。其中:由于过分依赖编码库造成漏编码1071例,占51%;培训不到位造成漏编码672例,占32%;手术记录不完整造成漏编码357例,占17%。结论编码员在编码时不仅应仔细阅读病历,还必须掌握手术编码分类原则及相关的医学知识,提高编码准确性,减少“另编码”的漏编。
Objective To analyze the factors of missed coding and other coding to enhance the integrity and accuracy of surgical coding. Methods The data of 10,000 surgical cases from 2012 to 2013 were retrieved by computer to learn more about the major surgical operations and to proofread the codes according to the principle of surgical classification. Results 1 000 medical records, surgical procedures omitted “other codes ” there are 2100, accounting for 21% of the number of copies. Among them, 1071 cases were caused by over-reliance on the code base, accounting for 51%; 672 cases were missed due to lack of training, accounting for 32%; 357 cases were found missing, accounting for 17%. Conclusions The coder should not only read the medical record carefully when coding, but also must grasp the classification principle of surgical coding and relevant medical knowledge, improve the accuracy of coding and reduce the omission of “another code ”.